Running head: DECREASING LOWER BACK PAIN WITH YOGA 1

Decreasing Lower Back Pain Among Adults Using Yoga

Aimee Achat

University of South Florida

DECREASING LOWER BACK PAIN WITH YOGA 2

Abstract

Clinical Problem: Many adults experience chronic lower back pain (CLBP), which increases

healthcare costs, perceived stress, and absence from work (Hartfiel et al., 2012).

Objective: The objective of the paper is to discuss if using yoga will decrease CLBP among

adults over three months. PubMed, CINAHL, and Google Scholar were accessed to acquire

practice guidelines and the procedures about using yoga for CLBP. The key search terms used

were lower back pain, yoga, well-being, complementary alternative medicine (CAM) therapies,

and alternative pain intervention.

Results: The literature demonstrated a decrease in CLBP rates when patients received yoga as

interventional therapy.

Conclusion: Patients with CLBP who performed yoga have a reduced incidence of CLBP, and

decreased stress. Further research is needed to validate whether yoga use will reduce CLBP

patients residing in the Western hemisphere.

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Decreasing Lower Back Pain Among Adults Using Yoga

Chronic lower back pain (CLBP) is one of the most common public health problems

affecting people of different socio-economic levels globally (Telles et al., 2016). Back pain is

featured in work-related stressors, both physical and psychosocial (Tekur et al., 2012). Many

workers have had absenteeism due to CLBP and it has cost the British governments budget an

estimated 17 billion per year (Hartfiel et al., 2012). The use of yoga therapy in this instance may

help to reduce pain and psychological problems in this population.

Background questions concerning this topic include: How does yoga affect psychological

stressors? Will yoga have an effect on the pathophysiology of the lumbar discs? Will yoga

decrease the costs of medical care? A relevant evidence-based practice (EBP) question is: (P)

Among adults with chronic lower back pain, (I) does yoga (C) compared to no yoga (O) affect

self-reported pain levels over three months (T)? The anticipated result is a reduction of lower

back pain within this patient populace.

Literature Search

PubMed, CINAHL, and Google Scholar were used to attain clinical trials and the

guidelines about CLBP and yoga use. The main search terms used were lower back pain, yoga,

well-being, complementary alternative medicine (CAM) therapies, and alternative pain

intervention.

Literature Review

Three randomized controlled trials (RCTs) were used to evaluate the efficacy of the

practice of yoga on CLBP. Hartfiel et al. (2012) evaluated the effects of yoga in treating

observed stress and back pain at work. The design of the study was a RCT with the sample size

of 74 participants aged 25 to 64 years. The participants were randomly assigned to the

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experimental yoga group (n=37), and to the no yoga control group (n=37). The experimental

group received one 50 minute Dru Yoga session each week for eight weeks while the control

group had no physical intervention but received a back pain education booklet during the same

time period but were offered yoga classes after the study. The yoga classes included activation

exercises, yogic postures, energy block release movements, and relaxation. Outcome measures

that were used in the study included the perceived stress scale (PSS) for measuring the

individuals perception of stress in their lives, Roland-Morris disability questionnaire (RMDQ)

for back pain, and the positive and negative affect schedule expanded (PANAS-X) used for

psychological well-being. There were significant decreases in back pain (p < .01), and perceived

stress (p < .01) compared to the control study. The strengths of the study involved included the

randomization of the two groups, the researchers included reasons why there was attrition, the

subjects were analyzed in their assigned groups, the control group was appropriate for the study,

the instruments were valid and reliable, and the subjects were similar in demographics and

baseline variables. The weaknesses were that it was unknown whether the researcher knew the

allocation of participants, follow-up assessments needed to be conducted to study the full effects

of the intervention, and the subjects of the control group were not hidden from the study group.

Tekur, Nagarathna, Chametcha, Hankey and Nagendra (2012) designed an active, single-

blinded, RCT to study changes in pain control, depression, anxiety and spinal mobility for CLBP

patients. The sample size was 80 adult patients, over the age of 18 years who reported having

chronic pain for over three months. The patients were randomized into a yoga experimental

group (n=40), or a physical therapy control group (n=40). All the applicants had a set daily

schedule over a week, in which the experimental group was given yoga techniques, breathing

and meditations while the control group had physical therapy movements, non-yogic breathing
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exercises, and lectures. The instruments used were a numerical rating scale for pain (NRS) and a

sit and reach measure (SAR). The result was that yoga reduced CLBP pain, anxiety, and

depression, and also improved spinal movement in patients with lower back pain more

effectively than physical exercises. Pain decreased by 49% in the experimental group (p < .001).

The strengths of the study included randomization of the subjects to the control and experimental

groups, the randomization was hidden from the providers, there were no dropouts from the study,

the follow-up assessments were long enough to entirely study the intervention effects, the

subjects were analyzed in the group to which they were randomized, the control group was

suitable for the study, the measurement tools were valid and reliable, and the subjects in each of

the groups were similar regarding the baseline variables. There was only one weakness of the

study which indicated that the subjects were not blinded to the intervention.

Telles et al. (2016) examined whether 12 weeks of yoga practice with participants who

had CLBP would result in differences in self-reported pain. The sample size was 40 adult

patients from 20 to 45 years old who had CLBP and degenerative changes. The patients were

randomized into a yoga interventional group (n=20), and a health teaching control group (n=20).

The assessments were reported through self-rated pain, state anxiety measure, spinal flexibility

test and magnetic resonance imaging (MRI) scanning. The yoga group was taught simple

exercises, yogic breathing techniques, and yogic chanting while the control group continued their

routine medical care consisting of analgesics or non-steroidal anti-inflammatory drugs (NSAID).

The result of the study was a 26.4% reduction in pain after 12 weeks of yoga among the

intervention group (p < .01). The strengths of the study included that the subjects were assigned

randomly to the two groups, analyzed in those groups, the assignments of the groups was

obscured from the researchers, and there were specific details for attrition provided.
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Furthermore, the control group was appropriate, the instruments were valid and reliable, and the

subjects in each of the groups were similar in standard clinical variables such as age, sex, and

socio-economic background. The weaknesses were that the subjects were not blinded to the

study, and the follow-up evaluations were not long enough to be conducted to fully examine the

effect of the intervention.

The guidelines for non-invasive treatment for CLBP by Qaseem, Wilt, McLean and

Forciea (2017) and is retrieved from the American College of Physicians (ACP) incorporates

RCTs, clinical guidelines and literature evidence. It is strongly recommended to use non-

pharmacological techniques for CLBP including mindful relaxation, acupuncture, exercise, yoga,

and multidisciplinary rehabilitation to name a few from the guideline.

Synthesis

Hartfiel et al. (2012) showed that there were significant decreases in perceived stress (p <

.01) and back pain (p < .01) in the experimental group. Tekur et al. (2012) reported that CLBP

decreased by 49% in the experimental group (p < .001). Telles et al. (2016) demonstrated a

26.4% decrease in CLBP after 12 weeks of yoga among the intervention group (p < .01).

In all of the mentioned studies, yoga has had helped decrease CLBP and stress which can

increase the need for non-pharmacological techniques in the future. According to Qassem, Wilt,

McLean and Forciea (2017), yoga resulted in a decrease in CLBP when scheduled for less than

twelve weeks. However, there is need for more research as many of the evidence was of

moderate to low quality.

Clinical Recommendations
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According to Qaseem, Wilt, McLean and Forciea (2017), there are strong

recommendations based on the American College of Physicians (ACP) to treat and prevent lower

back pain such as mindful mediation, acupuncture, exercise, and multidisciplinary rehabilitation.

There are other treatments that have fewer evidence for use but are still recommended such as tai

spinal manipulation, tai chi, motor control exercise, yoga, progressive relaxation,

electromyography biofeedback, cognitive behavioral therapy, operant therapy, low-level laser

therapy (Qaseem et al., 2017). Furthermore, there are interventions used to decrease CLBP

specifically with generalized pain such as trunk coordination, strengthening, and endurance

exercises, disability and centralization exercises (Delitto et al., 2012). According to Qassem,

Wilt, McLean and Forciea (2017), yoga resulted in a decrease in CLBP when scheduled for less

than twelve weeks. However, there is need for more research as many of the evidence in the

studies were of low to moderate quality.

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References

Delitto, A., George, S., Van Dillen, L., Whitman, J., Sowa, G., Shekelle, P., Denninger, T.,

Godges, J. (2012). Low back pain: Clinical practice guidelines. Journal of Orthopedic &

Sports Physical Therapy, 42(4), A7-A10. doi:10.2519/jospt.2012.0301

Hartfiel, N., Burton, C., Rycroft-Malone, J., Clarke, G., Havenhand, J., Khalsa, S.B.,

Edwards, R.T. (2012). Yoga for reducing perceived stress and back pain at work.

Occupational Medicine, 62(8), 606-612. doi: 10.1093/occmed/kqs168

Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for

acute, subacute, and chronic low back pain: A clinical Practice Guideline from the

American College of Physicians. Annals of Internal Medicine, 166(7), 514-530.

doi:10.7326/M16-2367

Tekur, P., Nagarathna, R., Chametcha, S., Hankey, A., & Nagendra, H. (2012). A comprehensive

yoga program improves pain, anxiety and depression in chronic low back pain patients

more than exercise: An RCT. Complementary Therapies in Medicine, 20(3), 107-118.

doi:10.1016/j.ctim.2011.12.009

Telles, S., Bhardwaj, A., Gupta, R., Sharma, S., Monro, R., & Balkrishna, A. (2016). A

randomized controlled trial to assess pain and MRI-based structural spine changes in low

back pain patients after yoga practice. Medicine Science Monitor, 22, 3228-3247. doi:

10.12659/MSM.896599